A lot of different ingredients have gone in to hospitals’ selection of where to start testing the reconciling procedures, and there has been a wide variation in their choices. For some, the emergence of a physician champion on a particular unit has dictated the choice. For others, a medication error has triggered activity in a specific location. Some hospitals combined their baseline data collection efforts with a mini-FMEA process to assess the areas with the greatest potential for problems.
The most common place for organizations participating in the Collaborative to start has been in pre-admission testing (PAT), where they can take advantage of the pre-admission contact with the patient to develop an accurate home medication list. For nursing units, there have been many provocative discussions about the advantages of starting on medical versus surgical units. Chronically ill patients on the medical floors are often at great risk because of multiple conditions, multiple medications. Surgical patients with underlying medical conditions are often on medications that will need to be re-started post-op, another significant safety risk.
While most hospitals are focusing on starting with the admission phase, there is lots of great evidence on the effectiveness of reconciling on transfer out of the ICU in preventing medication errors (see Pronovost P, et. al. Medication reconciliation: a practical tool to reduce the risk of medication errors. Journal of Critical Care. 2003 Dec;18(4):201-205.) Peter Pronovost’s work at Johns Hopkins on reconciling at transfer from the ICU is well documented on the qualityhealthcare.com WEB site, including his measurement template. Among our collaborative participants, one of our great success stories was a hospital with an extremely large mental health population that began their reconciling implementation in the ICU, with a very powerful MD champion who consistently used the evidence of the impact that failure to re-start psychotropic meds was having on their patient population!
Starting in the ED is not usually recommended, since not all patients will be admitted and the urgency of the environment results in clinician focus on other issues. However, there are opportunities to take advantage of wait times for patients who are being admitted to start the reconciling process by developing the home medication list. See additional comments below about some of the issues connected with reconciling in the emergency department.The most important thing, worth repeating, is, wherever you choose to start, start small
About 11% of our ED patients are admitted to the inpatient units. My main question is whether it makes sense to use the reconciliation form for every patient, or whether it should be reserved for admissions. What are other EDs doing in this regard?
Once you’ve proven both the need for reconciling and ironed out the process issues, then moving to the ED to try to jump-start the process for patients who will be admitted would likely be more successful.
Hospitals have taken different tacks in how they approach completing reconciling forms for patients in the ED. The majority, I think, wait until they have identified that the patient will be admitted. But there are also a number who try to take advantage of wait times in the ED to ensure that the patient's home medications are identified. There can be important safety benefits from this, especially in connection with identifying adverse medication reactions that may be the cause or contributor to the ED visit (case study in our example of errors reconciling can prevent: ED patient nearly dies when hospital fails to pick up that he was taking digitalis on the admission history; allergic reaction to digitalis needing immediate treatment, but significant delay resulted).
One participating hospital where a high percentage of patient volume
is through the ED reported using the ED visit as an opportunity to start
patient education on the importance of carrying an accurate medication
list with them at all times. They now give all patients who are not admitted
a completed medication card on discharge from the ED.
I think it is safe to say there will be more success with ED staff compliance if you perform reconciliation on those patients you are going to admit. We have found a greater success rate by doing that. However if the ED in question already uses a method to list a patient’s current medications, then doing reconciliation on all patients who come to the ED would be the way to go as then you are half way there and it would be accepted by the RNs. Many EDs do not get this info until they go to admit, so it makes sense to only reconcile if you are going to admit.
Note also that Holyoke let reconciling implementation teams work independently, adopting different forms for their ED which subsequently converged.
The Collaborative hopes to initiate a working group to facilitate sharing of electronic solution development among participants.